Characterization of Reentrant Circuit in Macroreentrant Right Atrial Tachycardia After Surgical Repair of Congenital Heart Disease

Abstract

MacroAT after SR-CHD requires a large area of low voltage containing >/=2 scars forming narrow channels. Ablation within the channels eliminates MacroAT.

Congenital Heart Disease in the Older Adult

“…[111][112][113] Multiple IART circuits are often present in the same patient. 102 Cavotricuspid isthmus-dependent atrial flutter that revolves around the tricuspid annulus may be a common circuit; however, unusual circuits are often present, particularly when the tricuspid valve is not present or is distorted.…”

HRS Policy Statement: Clinical Cardiac Electrophysiology Fellowship Curriculum: Update 2011

“…They should have experience in the use of three-dimensional mapping systems, techniques for retrograde and transseptal access, and should understand the underlying anatomy sufficiently to help to avoid complications. Patient selection and pre-procedure evaluation, including cardiac monitoring, exercise stress testing, echocardiography and cardiac catheterization in selected individualsEquipment Catheters types and associated curvesSheaths, including curves and usesEnergy sources, including the indications for cryoablationAnatomy 72 Epicardial coronary vesselsAtrial anatomy AV node and His bundleTriangle of KochSubeustachian isthmusCrista terminalisPulmonary veinsCoronary sinusSinus nodeNoncoronary sinus of Valsalva, and significance for atrial ablationTechniques and endpoints AVNRT 73-77 Types Slow/fastFast/slowSlow/slowOther variantsAblation of AVNRT Slow pathway (preferred method)Fast pathwayMapping techniques for radiofrequency ablation Slow potential guidedAnatomically guidedRelative accuracy of endpoints of ablation NoninducibilityJunctional AV beats during ablationElimination of slow pathway functionAV reentrant tachycardia 73-75,77,78 Risk stratification in patients with ventricular pre-excitationTypes OrthodromicAntidromicAtypical bypass tractsMapping techniques Anterograde activation mapping of the earliest ventricular activityRetrograde activation mapping of the earliest atrial activityBypass tract potentialsLeft-sided approaches TransseptalTransaortic valve retrogradeAtrial tachycardia (focal and reentrant) 79,80 Most frequent sites of origin: Crista terminalis, eustachian ridge, pulmonary veins, valve annuliMapping, including intracardiac pace mapping, three-dimensional mapping systemsUnderstanding of influence of prior surgery, atrial fibrosisEndpointsManeuvers to distinguish supraventricular tachycardia mechanism 47,81-83 Classification schemes Long RP versus short RPWide QRS complex versus narrow QRS complexManeuvers His refractory ventricular pacing (for narrow complex tachycardia) and atrial pacing (for wide complex tachycardia)Changes in tachycardia cycle length and VA time with bundle branch blockPara-Hisian pacingTachycardia ...…”

“…Techniques and endpoints AVNRT 73-77 Types Slow/fastFast/slowSlow/slowOther variantsAblation of AVNRT Slow pathway (preferred method)Fast pathwayMapping techniques for radiofrequency ablation Slow potential guidedAnatomically guidedRelative accuracy of endpoints of ablation NoninducibilityJunctional AV beats during ablationElimination of slow pathway functionAV reentrant tachycardia 73-75,77,78 Risk stratification in patients with ventricular pre-excitationTypes OrthodromicAntidromicAtypical bypass tractsMapping techniques Anterograde activation mapping of the earliest ventricular activityRetrograde activation mapping of the earliest atrial activityBypass tract potentialsLeft-sided approaches TransseptalTransaortic valve retrogradeAtrial tachycardia (focal and reentrant) 79,80 Most frequent sites of origin: Crista terminalis, eustachian ridge, pulmonary veins, valve annuliMapping, including intracardiac pace mapping, three-dimensional mapping systemsUnderstanding of influence of prior surgery, atrial fibrosisEndpoints…”

Catheter ablation of non-inducible atrial tachycardia after surgical repair of heart disease

“…Sustained AT generally results from macroreentry around the atriotomy scar and cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL). In such cases, we can identify the reentrant circuit using a 3-dimensional electroanatomical mapping system (3D mapping) [3] [4]. In a subset of cases, however, AT/AFLs are short in duration and/or noninducible, despite pharmacological provocation prior to catheter ablation.…”

“…Therefore, we planned to obtain a voltage map for finding the channels of AT and create a conduction block line between the channels and/or the atriotomy scar and the inferior vena cava (IVC) to prevent incisional reentrant AT. Using the CARTO XP system (Biosene-Webster, Diamond Bar, CA, USA), we obtained a right atrial activation map to identify the atriotomy scar by searching for linear double potentials (DPs) [3]. A DP was defined by the presence on the atrial electrogram of 2 discrete deflections per beat, separated by an isoelectric baseline [5].…”